Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula

Patient Guideline Summary

Publication Date: July 4, 2022

Last Updated: March 3, 2023

Objective

This patient summary means to discuss key recommendations from the American Society of Colon and Rectal Surgeons (ASCRS) for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula. It is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

Anorectal anatomy is complex. This guideline discusses three common conditions that can develop in that area:
- An anal fistula is an abnormal channel connecting the inside of the anus with the skin.
- An anorectal abscess is a pocket of pus near and related to the anus. It may arise from a fistula.
- A rectovaginal fistula is an abnormal opening between the rectum and the vagina.

An infection (abscess) can develop due to obstruction of small anal glands. Infections can create drainage passages (fistulas). Crohn’s disease, complicated childbirth, infection, or cancer can cause a rectovaginal fistula.

Symptoms include pain, swelling, fecal incontinence, bleeding, and drainage.

This patient summary focuses on the management of anorectal diseases.

Diagnosis

Evaluation should include a careful inspection of the anus and surrounding tissue, both inside and out.
Imaging may be considered for Crohn’s disease, immunosuppressed patients, or suspicion of an abscess.

Treatment

Anorectal Abscess

An acute anorectal abscess should be treated promptly with incision and drainage.
A fistulotomy (surgically opening the passageway) may be done at the same time.
Antibiotics may be prescribed for systemic infection or underlying immune suppression.

Anal Fistula

A simple fistulotomy may be sufficient for an uncomplicated anal fistula.
Other procedures are available for more complex fistulas.

Rectovaginal Fistula

Surgery may not be necessary for the initial care of rectovaginal fistulas, but repair procedures are available for any degree of complexity.

Anorectal Fistula Associated with Crohn’s Disease

Anorectal fistulas associated with Crohn’s disease are typically managed with a combination of surgical and medical approaches.

Local administration of mesenchymal stem cells is a safe and effective treatment for selected patients with refractory anorectal fistulas in the setting of Crohn’s disease.

Abbreviations

ASCRS: American Society Of Colon And Rectal Surgeons

Source Citation

Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2022 Aug 1;65(8):964-985. doi: 10.1097/DCR.0000000000002473. Epub 2022 Jul 5. PMID: 35732009.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.